ECG Basics
Electrocardiography (ECG or EKG [from the German Elektrokardiogramm]) is a transthoracic (across the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body.
The recording produced by this noninvasive procedure is termed an electrocardiogram (also ECG or EKG).
The PQRST
The PR Interval
Atrial depolarization + delay in AV junction
(AV node/Bundle of His)
(delay allows time for the atria to contract before the ventricles contract)
Horizontally
One small box - 0.04 s One large box - 0.20 s One large box - 0.5 mV
Vertically
Every 3 seconds (15 large boxes) is marked by a vertical line. This helps when calculating the heart rate. NOTE: the following strips are not marked but all are 6 seconds long.
Rhythm Analysis
1: 2: 3: 4: 5:
Calculate rate. Determine regularity. Assess the P waves. Determine PR interval. Determine QRS duration.
Option 1
Interpretation? 9 x 10 = 90 bpm
Option 2
Find a R wave that lands on a bold line. Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes 100, 4 boxes - 75, etc. (cont)
Option 2 (cont)
Interpretation?
Look at the R-R distances (using a caliper or markings on a pen or paper). Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular?
Interpretation?
Regular
Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS? Interpretation? Normal P waves with 1 P wave for every QRS
Interpretation?
0.12 seconds
Interpretation?
0.08 seconds
Rhythm Summary
Etiology: the electrical impulse is formed in the SA node and conducted normally. This is the normal rhythm of the heart; other rhythms that do not conduct via the typical pathway are called arrhythmias.
NSR Parameters
AV Nodal Blocks
Rhythm #1
PR Interval
> 0.20 s
Rhythm #2
PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).
Etiology: Each successive atrial impulse encounters a longer and longer delay in the AV node until one impulse (usually the 3rd or 4th) fails to make it through the AV node.
Rhythm #3
Etiology: Conduction is all or nothing (no prolongation of PR interval); typically block occurs in the Bundle of His.
Rhythm #4
The P waves are completely blocked in the AV junction; QRS complexes originate independently from below the junction.
Etiology: There is complete block of conduction in the AV junction, so the atria and ventricles form impulses independently of each other. Without impulses from the atria, the ventricles own intrinsic pacemaker kicks in at around 30 45 beats/minute.
When an impulse originates in a ventricle, conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.
Axis
Axis refers to the mean QRS axis (or vector) during ventricular depolarization. As you recall when the ventricles depolarize (in a normal heart) the direction of current flows leftward and downward because most of the ventricular mass is in the left ventricle. We like to know the QRS axis because an abnormal axis can suggest disease such as pulmonary hypertension from a pulmonary embolism.
We can quickly determine whether the QRS axis is normal by looking at leads I and II.
QRS negative (R < Q+S)
If the QRS complex is overall positive (R > Q+S) in leads I and II, the QRS axis is normal. In this ECG what leads have QRS complexes that are negative? equivocal?
QRS equivocal (R = Q+S)
How do we know the axis is normal when the QRS complexes are positive in leads I and II?
The answer lies in the fact that each frontal lead corresponds to a location on the circle.
Limb leads
I = +0o
II = +60o III = +120o Augmented leads 180o
avR -150o
avL I I
avL = -30o
avF = +90o avR = -150
o
150o 90o
III
II II
avF
The normal QRS axis falls between -30o and +90o because ventricular depolarization is leftward and downward. Left axis deviation occurs when the axis falls between -30o and 90o. Right axis deviation occurs when the axis falls between +90o and +150o. Right superior axis deviation occurs when the axis falls between between +150o and -90o.
QRS Complexes
A quick way to determine the QRS axis is to look at the QRS complexes in leads I and II.
I + + -
II + +
The 12-Leads
The 12-leads include:
3 Limb leads (I, II, III) 3 Augmented leads (aVR, aVL, aVF) 6 Precordial leads (V1- V6)
ST Elevation
One way to diagnose an acute MI is to look for elevation of the ST segment.
ST Elevation (cont)
Elevation of the ST segment (greater than 1 small box) in 2 leads is consistent with a myocardial infarction.
Interpretation
Yes, this person is having an acute anterior wall myocardial infarction.
Other MI Locations
First, take a look again at this picture of the heart.
Other MI Locations
The limb and augmented leads see electrical activity moving inferiorly (II, III and aVF), to the left (I, aVL) and to the right (aVR). Whereas, the precordial leads see electrical activity in the posterior to anterior direction.
Anterior MI
The anterior portion of the heart is best viewed using leads V1- V4.
Precordial Leads
Lateral MI
Lateral portion of the heart is best viewed
Leads I, aVL, and V5- V6
Inferior MI
For inferior portion of the heart
Leads II, III and aVF
Inferior Wall MI
This is an inferior MI. Note the ST elevation in leads II, III and aVF.
Anterolateral MI
This persons MI involves both the anterior wall (V2-V4) and the lateral wall (V5-V6, I, and aVL)!
When myocardial blood supply is abruptly reduced or cut off to a region of the heart, a sequence of injurious events occur beginning with ischemia (inadequate tissue perfusion), followed by necrosis (infarction), and eventual fibrosis (scarring) if the blood supply isn't restored in an appropriate period of time. The ECG changes over time with each of these events
ECG Changes
Ways the ECG can change include:
ST elevation & depression
ST Elevation
ST Elevation Infarction
The ECG changes seen with a ST elevation infarction are:
ST Elevation Infarction
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI B. Ischemia from coronary artery occlusion results in ST depression (not shown) and peaked T-waves C. Infarction from ongoing ischemia results in marked ST elevation
D/E. Ongoing infarction with appearance of pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Qwaves, but normal ST segment and Twaves
ST Elevation Infarction
Heres an ECG of an inferior MI:
Look at the inferior leads (II, III, aVF). Question: What ECG changes do you see?
ST elevation and Q-waves What is the rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
When analyzing a 12-lead ECG for evidence of an infarction you want to look for the following:
Abnormal Q waves ST elevation or depression Peaked, flat or inverted T waves ST elevation (or depression) of 1 mm in 2 or more contiguous leads is consistent with an AMI There are ST elevation (Q-wave) and non-ST elevation (non-Q wave) MIs
Right BBB
QRS complex widens (> 0.12 sec). QRS morphology changes (varies depending on ECG lead, and if it is a right vs. left bundle branch block).
Rabbit Ears
Normal
In this step of the 12-lead ECG analysis, we use the ECG to determine if any of the 4 chambers of the heart are enlarged or hypertrophied. We want to determine if there are any of the following:
Right atrial enlargement (RAE) Left atrial enlargement (LAE) Right ventricular hypertrophy (RVH) Left ventricular hypertrophy (LVH)
Take a look at this ECG. What do you notice about the P waves?
The P waves are tall, especially in leads II, III and avF.
II V1 or V2
Take a look at this ECG. What do you notice about the P waves?
Notched
Negative deflection
The P waves in lead II are notched and in lead V1 they have a deep and wide negative component.
II V1
> 0.04 s (1 box) between notched peaks, or Neg. deflection > 1 box wide x 1 box deep
Normal
LAE
Take a look at this ECG. What do you notice about the axis and QRS complexes over the right ventricle (V1, V2)?
There is right axis deviation (negative in I, positive in II) and there are tall R waves in V1, V2.
Compare the R waves in V1, V2 from a normal ECG and one from a person with RVH. Notice the R wave is normally small in V1, V2 because the right ventricle does not have a lot of muscle mass. But in the hypertrophied right ventricle the R wave is tall in V1, V2.
Normal
RVH
V1
Take a look at this ECG. What do you notice about the axis and QRS complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?
The deep S waves seen in the leads over the right ventricle are created because the heart is depolarizing left, superior and posterior (away from leads V1, V2).
There is left axis deviation (positive in I, negative in II) and there are tall R waves in V5, V6 and deep S waves in V1, V2.
S = 13 mm
R = 25 mm
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